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I took some time off for the holidays, and my clients seem to be reacting to this. A few have cancelled sessions, a few have arrived late when they’re usually on time, and one said he thinks it’s time to stop therapy even though there is clearly more to do. How can I bring up the possibility that they’re upset about my being away without making the therapy all about me?

I agree with your assessment that your clients are having reactions to your absence and that it’s desirable to encourage them to talk about their feelings instead of demonstrating them in action. I’ll share some ideas about ways you can initiate this discussion and some of the reasons that clients may be reluctant to acknowledge and talk about their feelings.

Before talking with your clients about their reactions to your absence, notice and work to understand your countertransference feelings about this. You may feel annoyed, afraid, or guilty, reflected in thoughts like “don’t they appreciate how hard I work?” or “what if I lose clients every time I’m gone?” or “I guess I shouldn’t take so much time off next year.” These countertransference feelings can interfere with your ability to talk with the clients about their feelings, so wait to do so until you have understood and gotten support to process your annoyance, fear, guilt, or other feelings.

Your clients will probably have difficulty acknowledging to themselves and to you that they were affected by your absence. Our society generally values independence and autonomy over connection and interdependency, and it is unusual and unfamiliar for a professional to acknowledge the impact of a break in the relationship. Other health care and social service providers generally don’t acknowledge that the client may be affected by the provider’s absence or lack of availability. In addition, some of your clients probably coped with difficulties in their families of origin by denying their need for reliability and consistency and by shutting off their awareness of feelings of dependency and accompanying anger when their relational needs weren’t met.

Despite your clients’ reluctance and lack of practice, there are ways you can introduce the topic that will make it easier for them to engage in exploring their reactions to your time away. First, notice for yourself how the client’s behavior is different and mention this with an attitude of curiosity. For example, you might say “I notice that you were late for both of our sessions since I returned from my holiday break. That’s unusual for you, and I wonder if it might be related to the fact I was gone for a couple weeks.” This opening statement doesn’t make any judgment or assumption but simply tracks the change in behavior following your absence.

Second, it may help to make a statement that normalizes the fact that clients are affected by a break in the flow of therapy and that these emotions can be at odds with their rational or intellectual understanding of the reasons for the break. A sample statement would be “Many clients find they have feelings about missing a week or two of therapy, even though they understand the reason for my being away. Could that be the case for you?” With a client who is especially reluctant to look at her feelings about the therapy relationship, you might also talk about why this could be important to look at in light of her presenting issue or the focus of treatment. An example is “It may seem odd for me to ask about your feelings related to my being away for two weeks, but we’ve been talking about how you feel when your husband is on a business trip. It might help us understand that better if we also look at your feelings when I’m away.” This gives the client an explanation for why you think it is important to explore this and how it could help her in the area of concern to her. In some cases, it can be helpful to make a statement about the early experiences and coping strategies that interfere with acknowledging the impact of your absence by saying something like “We’ve been discussing how hard it was for you to come home to an empty house when both of your parents were working, and some of those feelings may have returned when I was away. You’ve worked hard to not let yourself know how painful that was, and it may be hard to recognize how you felt while I was gone.”

Last, let the client know that you’ll continue to notice and bring up the question of her feelings when you are away in the future. Sometimes the repetition over time helps the client to develop more awareness of the underlying emotions that aren’t accessible in your initial discussion.

I hope you are able to use these suggestions when working with client reactions to your absences. Please email me with comments, questions, or suggestions for future blog topics.

I’ve been seeing a client for three months, but she has only come to 7 sessions. Sometimes she calls to cancel, but often she just doesn’t show up. I don’t know whether I should stop seeing her or if there is another way to help her understand the importance of coming in regularly.

This is a common dilemma, especially for clinicians in training or agency settings. It is difficult to make therapeutic progress when clients miss one or more sessions each month, and it is often challenging to engage the client in examining the reasons for irregular attendance. I will describe two approaches to this issue, and you may find either or both of these approaches helpful with this client and similar situations.

The first approach involves having a standard policy regarding attendance, setting a limit on the number of missed appointments or late cancellations. Your agency may have such a policy or you may develop one if you are working in a private practice setting. This policy should be part of your informed consent process, and I recommend that you remind the client about this each time she misses an appointment without notice or with late notice. A common standard is to allow three missed appointments or late cancellations (usually less than 24 hours’ notice) in a four month period before ending treatment. You may decide to make exceptions for illness or unavoidable emergencies, but be sure to discuss this with the client and let her know the reason for making an exception. The purpose of this type of policy is to insure that there is discussion about the issue of attendance and that the client is able to make progress on the issues she wants to address.

The second approach, which can be used instead of or in addition to an attendance policy, is to handle the client’s sporadic attendance as a clinical issue. The basis for this approach is an assumption that the client is repeating a traumatic or maladaptive interpersonal relationship and that you can provide the client with a different experience that will have a therapeutic outcome. I will outline a three step process for making such a clinical decision.

The first step in understanding the meaning of the client’s missed sessions is to reflect on her developmental history, especially regarding attachment and loss, and her descriptions of current relationships with intimate partners. Identify one or two themes that are present in these early and recent relationships. One common theme is an unpredictable attachment figure which leaves the client with feelings of longing and inadequacy. Another is an intrusive or abusive attachment figure leading the client to sacrifice safety to meet her need for connection. Think about the implications of these interpersonal experiences for the client’s view of herself and expectations of others.

The second step is to examine your countertransference and identify the interpersonal experience that the client is repeating with you. Be honest and thorough in reflecting on all of the thoughts, emotions, and images that are present when you wait for your client or when you pick up a message cancelling a few hours before the appointment. Notice any attributions you make about the reasons for the client missing the appointment and about the value of the therapy or your value as the therapist. Think about parallels between your thoughts and emotions and the client’s interpersonal themes. The client may be placing you in the position of the attachment figure or in the more vulnerable position she was in as a child.

Once you have identified the relevant experience and the roles being enacted by you and the client, you are ready to decide on a response that will allow the client to experience this interaction differently. This third and final step usually begins with shifting your countertransference state so that you are in touch with your therapeutic intentions and skills. You can then talk with the client in a different way than is possible when you are in the grip of the client’s enactment. In the best of circumstances, your response allows the client to become more engaged in the therapy whether or not she gains insight into the nature of the repetition. At other times, the client continues her side of the repetition, and you will need to decide whether to introduce limits as discussed above. Even in these situations, however, there is an opportunity for your learning and you can end the therapy, if necessary, knowing that you provided every opportunity for a therapeutic outcome.

I hope you are able to use these suggestions when working with clients whose attendance is irregular. Please email me with comments, questions, or suggestions for future blog topics.